One of the objections about assisted dying legislation is that vulnerable people will die, through coercion, because they feel like a burden on their families, for financial gain, or because their care is expensive or onerous. These are valid concerns to have – we know that there are unscrupulous people who take advantage of even their own relatives, that not all health practitioners are wholly ethical, and that there are financial pressures on health facilities at every level. And many of us have heard reports from overseas about people who didn’t meet the criteria being killed under the auspices of assisted dying laws, or weren’t reported to the government. While on closer examination these reports invariably turn out to be distortions or unsubstantiated allegations, a topic I may address at another time, the fear they address is a reasonable one – even if they haven’t happened, they could.

Last week, when I briefly summarised the final report of the voluntary assisted dying expert advisory panel, I mentioned some of the 68 safeguards that are in place. Today I’ll go into detail about the requirements and regulations that will be implemented to prevent this legislation being misused.

The first six safeguards ensure that requesters meet all of these threshold requirements before the process starts. They must:
• be eighteen or older (this law will not apply to minors),
• be resident in Victoria (people can’t travel here to die with assistance),
• be competent to make significant medical decisions (using the same standard the Medical Treatment Act, 2016, requires),
• have a life-limiting condition, illness, or disease (e.g. metastatic cancer, end-stage heart failure, motor neurone disease),
• have a prognosis of twelve months or less (their death is inevitable, and not distant), and
• be ‘experiencing enduring and unbearable suffering that cannot be relieved in a manner the person deems tolerable’ (e.g. for that person it may not be acceptable that the only analgesic dose sufficient to make their pain bearable makes them unconscious),

Note that a person must meet all of these criteria before the process of assessment can begin; in contrast, in the US people do not need to be suffering, while in Europe it isn’t required that they be dying.

The legislation specifically notes that disabilities and mental ill-health are neither barriers to, nor reasons for, voluntary assisted dying. In other words, someone may not access assisted dying because they have, for example, significant cerebral palsy, or are paraplegic, or have clinical depression, or schizophrenia – the requirements for a life-limiting illness, condition, or disease, a terminal prognosis of under a year, and enduring suffering, apply universally. Conversely, people who meet all the other criteria cannot be deemed ineligible because of a physical disability or mental ill-health.

The rest of the safeguards are divided into areas of protection. First are measures to ensure that the request process is voluntary:
• health practitioners are prohibited from bringing up the option of assisted dying with their patients – it must come from them,
• nobody except the person can request on their behalf, even someone with medical power of attorney and an advanced directive demonstrating that this is what they want,
• there must be three requests, over at least ten days, one of which must be written, and witnessed by an independent person, and
• the person can change their mind at any time, including after the prescription has been filled.

Next is the process of assessment, which is clearly and tightly described:
• two independent, experienced medical practitioners must separately assess the person (overseas this typically takes 60-90 minutes per consultation),
• only doctors who have undertaken specialized VAD training may be involved,
• the two assessing doctors are designated the coordinating practitioner and the consulting practitioner, each with well-defined duties, and
• either doctor may, and is obliged to, refer the patient to a mental health professional if they have concerns about the person’s decision-making capacity,

There have been concerns about prescribed medication going missing or being taken accidentally. To that end, the following measures will be introduced:
• the prescribing doctor must have a specific permit,
• the patient must nominate a contact person who agrees to take responsibility for returning the medication to the dispensing pharmacist if it is unused,
• from the time it is dispensed until it is taken or returned, the clearly labelled medication must be stored in a locked box,
• if the patient is unable to self-administer (e.g. is unable to swallow, has restricted arm movement), the coordinating doctor (and only the coordinating doctor) may administer the medication, and
• in that case the doctor must have additional certification, and the administration must be witnessed by someone who is independent of the doctor.

Unsurprisingly, health professionals, particularly doctors and nurses, have concerns about their roles, from being forced to perform acts with which they object, to being prosecuted. To protect them,
• health practitioners may conscientiously object to participating,
• there are protections for health practitioners who are present at the time of administration, and
• health practitioners will be required to report any practitioner acting outside the legislation.

There was a question raised about criminal consequences for health professionals who act outside the scope of the legislation – initiating a discussion about the option of assisted dying, for example. That is not specifically addressed, as there are already consequences for health practitioners who break the law or otherwise act in breach of the standards of each registered profession (one of which includes following the law), and charges of manslaughter and murder are not affected by the introduction of voluntary assisted dying legislation – it is still a crime to aid or to abet a suicide, or bring about someone’s death, except for the carefully delineated circumstances surrounding this Act. There will, however, be new laws introduced: failing to report any step, inducing or influencing a person to request or participate in assisted dying, and falsifying reports to the oversight and review panel will be criminal offences.

Finally, there have been allegations that not all deaths overseas that take place under the auspices of an assisted dying framework are reported or investigated appropriately. In Victoria, part of the process includes the creation of an independent multidisciplinary oversight and review panel. They are notified at every step of the process, from the first formal request to notification of death. Included in this process is notification whenever a prescription written to assist dying is filled. The patient’s contact person is tasked with returning the medication when the patient dies, if it was not used; if they fail to do so, the panel is empowered to follow up with them about the location of the medication, and ensure it is safely accounted for.

The oversight and review panel’s role will be enshrined in legislation, and it will have the capacity to refer breaches of the legislation to the appropriate authorities, from the health regulator AHPRA to the police. The panel will review every case, transparently report publicly, and publish a review after five years.

The expert advisory panel estimates that it will take eighteen months to set up all of the required safeguards (e.g. medical education) and legislative changes, before the first requests can be made.

But first the Bill has to get through both Houses of parliament. Which is where you can come in: if you support the legislation and you live in Victoria, please contact your lower and upper house MP’s to let them know – they can’t represent their constituents if they don’t know what you want.

I’ve just left a briefing session at Victorian Trades Hall about the upcoming Federal election, and I’m far more alarmed about the future workers face under an Abbott-led government than I was an hour and a half ago. I knew that the Liberal party in general, and Mr Abbott in particular, are not and never have been friends of the worker.

I was a job rep during the WorkChoices era, and I remember protesting against the IR legislative changes that threatened working conditions of not just my profession but those in every industry. But though 2005/2006 fees like last week for me, there are a lot of people working in Australia now who weren’t affected, involved or otherwise aware of what it entailed, so here’s a brief (I promise!) overview.

WorkChoices was promoted as simplifying an over-regulated collection of IR legislation – instead of a number of Awards, and processes for renegotiating Awards once they expired, WorkChoices detailed a set of universally applicable minimum conditions, covering maximum ordinary hours, minimum wage, wage structure, and some leave provisions (minimum hours of annual, parental, and personal or carers’ leave) – everything else was up for negotiation.

The key pillars of WorkChoices were:

cutting penalty rates and other Award entitlements

the introduction of individual contracts instead of Awards

weakening Unfair Dismissal laws

reduction in the ability of unions to represent members

removing the “no general disadvantage” rule

While the signing of an individual workplace agreement was voluntary, unfair dismissal laws no longer applied to companies with fewer than 100 employees, and could be offered as a condition of employment to new hires.
The key phrase used by the Liberal party was “flexibility” – WorkChoices would allow employees greater flexibility of hours, and allow them more freedom to trade previously-protected conditions. That’s a word Victorian nurses and midwives heard a lot of during our 2011/2012 campaign – primarily about the idea of bringing in short and split shifts, so that we could have the ‘flexibility’ of working only during the busiest parts of the day (four hours from 7AM, for example, and then back in the evening, with an allegedly family friendly gap in the middle of the day), and the ‘flexibility’ to work on different wards or even different campuses of the same network, potentially on the same day.

Mr Abbott’s said that WorkChoices is “dead, buried, cremated” and his new policy is more neutral than big business would prefer, but on close examination his recently unveiled IR policy looks awfully familiar.

I’ll briefly expand on what this means for a couple of points. First, Individual Flexibility Agreements (IFA’s) will be a mandatory requirement of any new Enterprise Bargaining Agreement, allowing an Agreement-covered employee to opt for individual conditions – a move they can reverse but only 13 weeks after giving written notice.

Under current Fair Work legislation, employers have to sit at the negotiating table in good faith – under proposed changes workers may have to sue uncooperative employers to even start the process.

Not that this will necessarily help. Mr Abbott’s said Greenfields Agreements (which are the business’s version) can be taken to Fair Work for approval if there’s no agreement after three months of negotiations – in essence allowing the employer to stall for thirteen weeks, then unilaterally negotiate conditions. For Victoria’s nurses and midwives that would have meant the death of ratios, the introduction of assistants, and the return (after over fifty years) of split shifts, with nothing we or our union could do about it.

And Mr Abbott’s said he’ll reintroduce the Australian Building and Construction Commission – ostensibly designed to provide oversight, last time around the ABCC served to reduce the effectiveness of the CFMEU, who are predominantly portrayed as a latter-day BLF filled with thugs and stand over men; the ABCC’s sole accomplishment was a sharp jump in the number of deaths in mining and on construction sites, which is unsurprising when you have one side seeing occupational health and safety as a tactic to allow union officials access, and the other side viewing OHS as a way of keeping workers safe. As we’ve recently seen in Melbourne, when OHS mechanisms are compromised (assessing the structural soundness fo a wall before adding a wind-catching load to it, for example) people can die.

But the biggest giveaway is that Mr Abbott intends to institute a Productivity Commission – tasked solely with questions of productivity, including during periods of negotiation, and not taking into account fairness, equity or the livability of conditions, the commission will make recommendations; unless Mr Abbott doesn’t intend to implement at least some of those recommendations (in which case the cost of the Commission is an enormous boondoggle), that means anything is potentially open to change regardless of pre-election promises. And Mr Abbott’s already said that his word isn’t necessarily his bond.

Abbott knows his IR policy is a litmus test for many swinging, somewhat egalitarian suburban voters on what kind of society the Coalition thinks we should live in — therefore radical change is likely; sneaky, incremental reform is a definite; and, despite the oft-repeated claims of the business lobby, arguably the pendulum has already swung.

Is he right? The pendulum may be swinging, but the election outcome’s still in the balance – current projections are an even split, with Independents holding the balance of power. There are 38 pivotal seats, three (Corangamite, Deakin and McEwen) in Victoria, where the outcome is down to a couple of thousand votes.

What can we do to protect workers’ rights? The biggest tool any of us has to effect change is discussion – talking with friends, family and colleagues about what an Abbott-led government would mean for them, their families, their colleagues and their futures. Face to face is best, but using social media platforms like Facebook to spread information is also effective.

And for those who want to do more, ACTU-affiliated unions are campaigning hard – you can visit their website, or contact your own union to ask about door knocking, manning an information stall, making calls to members, or otherwise getting out the word. And if you’re not currently a member of union? There has never been a better time to join – there really is nobody else who’s loooking out for the best interests of you and your industry or profession.

I know that this is a difficult election decision for many – internal friction has done the ALP no favours, and Mr Rudd’s asylum seeker policy has disenchanted many on the Left, and the Liberal’s continuous attacks on the strength of our economy, while inaccurate, have been convincing, if only by sheer repetition. We have a potentially unique case of two leaders who’re unpopular with much of the electorate in general, and with many of those traditionally aligned with their party. I know a number of people who are genuinely undecided, and several who intend not to cast a valid vote. To the latter I say this: in an election this close, a wasted vote is a vote for the Liberal party, and that means it’s a vote for IR inequity.

For undecided voters it’s a decision about what’s best for you, for your family, for your community and for your country, in whatever order of importance you have. Know that nowhere in the world has disadvantaging workers stimulated an economy – the less people have to spend, the less they spend, so business savings offsets of reduced employee wages and conditions are countered by the fact that those employed by businesses around you have less money for your goods and services. Know that the public services cut by conservative governments are those you will need (transport, hospitals, emergency services, maintenance, TAFEs), and they’re far more expensive to reinstate than to maintain. Know that conservative governments have and continue to privatise public assets, which gives coffers a short-lived boost in exchange for less oversight, no ongoing revenue, often poorer service, and almost always for a higher cost. And think about the kind of future you want our children to have – the education and training opportunities available to them, the safety supports if they develop mental and/or physical illnesses, their options if their employment’s unfair, and the safety of their workplaces.

When it comes down to it, the difference between my position and Mr Abbott’s on industrial relations is this – I start from a premise that many employers are fair, and committed to balancing their profit against the best interests of their employees, but we have to have inbuilt protections to safeguard against those who will jeopardise the wellbeing (financial, psychological, physical) of workers for their own gain; Mr Abbott believes that “Bad bosses, like bad fathers and husbands, should be tolerated because they do more good than harm.” Some bad fathers rape, abuse and kill their children – and we have laws in those cases to help protect the vulnerable and punish the guilty.

On June 1st the Agreement covering NSW public sector nurses and midwives expires. The NSW Nurses’ and Midwives’ Association has carefully compiled a log of claims, which is explained in this clip

They’ve tabled anything above an inflation-level pay increase of 2.5% and are focusing on not just maintaining and improving existing nurse/midwife: patient ratios, but introducing ratios in new sectors – in many cases areas where Victoria and California, currently the only other places that have legally mandated ratios, don’t have ratios.

My colleagues launched their campaign on Tuesday, with a rally outside Parliament House – and fellow active rep Chris Morgan and I had the very great honour of being asked to attend.

Chris Morgan, bringing a little Victorian red to the NSW blue scrub army as they march toward Parliament House, Sydney

I was really impressed by the size of this initial show of resolve and strength. I couldn’t fit them all in one shot, or even two – so, in a pan from left to right, here’s an idea of their commitment and presence:

Those used to red shirts, as worn by ANF (Vic. branch) members during our 2004, 2007 and 2011/12 campaigns will note that the NSWNMA have changed tack – for this campaign they’ll be wearing blue scrub tops, as modelled by NSWNMA General Secretary Brett Holmes (here addressing the rally):

I suspect that these functional, professional tops will become as familiar to the NSW public as our red was.

Chris and I weren’t just observers – we had the very great honour of speaking to staff and delegates about our experiences during our campaign. My presentation focused on the events leading up to the campaign, and a predominantly chronological account of how things unfolded from a member perspective, emphasising the contributions members can make.

Among other things, I spoke about the importance of maintaining enthusiasm and motivation – and that, toward the end of the campaign, I played the clip below, about the NSWNMA’s brilliant, ratio-winning 23010 campaign, every night. I was delighted to learn that Carolyn Guichard, who created this short film that so encouraged and lifted me in those last six weeks or so, is a nurse and NSWNMA member.

Chris’s passionate and rousing speech centred on the emotional journey and personal growth of her participation in the campaign. She discussed the power of social media for communicating quickly; the spirit of friendly competition that grew between hospitals (for the best catering on walk outs, highest media presence, biggest numbers etc); and the role of ninja-like presences at events where the Premier or Health Minister were present – Chris was given a half-hour tip-off that Victorian Health Minister David Davis was visiting Frankston Hospital, and she managed to gather almost fifty nurses to greet the minister, in an event that led the news:

This was Chris’s first ever public speech – her passion and the impact of her words was reflected in her receiving a standing ovation, led by NSWNMA General Secretary Brett Holmes. Chris embodies something I discovered through fighting our campaign, and which I shared with my audience – we are all capable of far more than we realise.

I know I always thought that extraordinary things were done by extraordinary people – it turns out that quite ordinary people, like me, like Chris, and like you, can achieve them, too.

The NSWNMA is constructed and run quite differently from ANF (Vic. branch) – one of these differences is a six-weekly meeting of representatives from each branch of the Association, which is the audience Chris addressed. These kinds of differences were part of what made visiting another arm of my union so interesting and useful – I think I learned as much from them as I hope they did from us.

I’ll be keeping an eye on the progress of my colleagues in NSW, and I wish them every success.I would be delighted to contribute in any way I can, because I know how important this is. I hope their campaign is resolved quickly – I don’t know if I could have sustained the fight had I known at the outset how ling it would take. On the other hand, it was the sheer bullheadedness and unreasonable resistance to fair negotiation on behalf of the Baillieu government (and their negotiators, VHIA) that kept me fighting with renewed rage and commitment.

Like ours, this is not a fight about money – it’s a fight to keep the nursing and midwifery workforces healthy, and the population of NSW safe. NSW’s nurses and midwives already know they can fight. They know they have the unity, drive, creativity and passion to win, and after two years of ratios they not what losing means for their patients, their communities, and their professions. Make no mistake – though governments somehow continue to fail to recognise their worth, nurses and midwives know that ratios are essential for the provision of safe, quality care. There is nothing more important, there is nothing that can distract them, and there is nothing that NSW nurses and midwives will accept in exchange for anything less.PS It’s 742 days until NSW votes. For Victoria it doesn’t matter whether it’s Ted Baillieu, Denis Napthine, or whoever’s LNP leader on November 29th 2014 – the underlying party ideology is still the same, and we know that an LNP government is bad for nurses and midwives, and bad for our communities. 618 days for us, and counting…

I recently wrote about the disappointment I felt at the distortion of our EBA campaign by the Left wing press. Though I posted links to support my claims, I didn’t address any articles individually – spurred on by a post today on the ANF’s Facebook page (by a person who hasn’t posted there previously), I shall explore one of the articles I referenced earlier this week, and which Dusty Duncan (apparently an ANF member) brought to the attention of our membership with the alarming introduction:

Read the truth fellow nurses. We got shafted by OUR OWN UNION! The ANF is in bed with the government and hospitals. You take an ANF official along to any meetings for support and chances are, they will there to get the best deal for THE HOSPITAL.

The article to which Ms or Mr Duncan linked is “Australian nurses’ union imposes real wage cut” by Patrick O’Connor and which was published on the World Socialist Web Site a day after the final acute public sector statewide members’ meeting.

I shall address the claims Mr O’Connor, a candidate for the upcoming Melbourne by-election, makes in both general terms and take up specific points. I imagine that readers of the WSWS need no notification of Mr O’Connor’s biases.

I ought to be upfront about mine – I have been a member of and a job rep for the ANF since September 1992, the month I first registered. I have been involved with all the campaigns since then, but must confess to not having been a particularly good rep – I haven’t attended tri-annual training, and have been to only one of the annual Delegates conferences. However, I not only strongly support the activities of the Federation, I have been impressed with the strength, integrity and determination of the two state Secretaries who’ve served ANF (Vic. branch) since I joined – first Belinda Morieson and, since 2001, Lisa Fitzpatrick. My faith in them has never wavered, for they have never given me cause.

Since December, because of the campaign, I had the privilege of spending a lot of time with ANF staff across a range of roles, from the current Executive and members of the previous Executive, to organisers, media, recruitment and support staff. I have, without exception, been impressed and awed by their dedication and commitment to, and passion for our best interests. Even more than that I have been stunned by their integrity.

Let’s start with the first paragraph, where O’Connor opens with a clear indication of where he stands, branding the Agreement as a “sell-out deal” that was “quickly rammed through a mass meeting of members…” and which resulted in “a substantial real wage cut and a significant… ero[sion]” of ratios. There are two other matters, which are expanded on later, so I’ll address them then.

I suspect that anything short of a 25% pay increase and full retention of conditions would have been seen as collusion and/or selling out, and that’s an ideological position I can’t address with facts. I can, however, speak to the speed with which the Agreement was accepted – we were given the same time frame and opportunity to ask questions before voting in favour of this EBA on March 16 as we’ve been given previously, with the new requirement of AEC-overseen voting: the EBA was overwhelmingly accepted.

Paragraph two gives a brief and benign overview of our actions during the campaign. Paragraph three, on the other hand, is the opening salvo in a pitched anti-Federation battle: “However, the overriding priority for the ANF bureaucracy was to maintain their privileged position within the health sector and to prevent the nurses’ dispute from developing into a political struggle against the state and federal governments.”

I imagine, from O’Connor’s tenor throughout, that the privileged position here is that of the Executive and officials, rather than any esteemed position nurses and midwives themselves hold (the Health Minister is on the record as only acknowledging that nursing care “may contribute positively to a person’s life expectancy or to the quality of life they experience” – source; emphasis added). It’s an extraordinary claim, and I’m very interested to know what the author means by this, as he doesn’t expand on or support it subsequently. The AMA, perhaps, has a privileged place, insofar as the degree to which it’s consulted by state government, and the Allied Health unions are generally quite quiet, but as their combined members total a fraction of the roughly 93,000-strong number of nurses and midwives registered in Victoria (some 70% of whom are ANF members) that’s not surprising.

I would not be surprised to learn that the ANF Executive took into account not just what is currently happening politically on a local level but also the dynamics involved Federally, and in other states and territories – we are a branch of a national union, we have to negotiate for Federal funding (particularly in aged care, which is predominantly federally funded), and we operate in the complexity that is the real world. It is not now and, to the best of my knowledge, ever has been the case that Federal politics is embroiled in state industrial matters – even in 1986 the dispute was local. The only kind of exception I can imagine would be if the state and federal government’s were the same party, and a local issue promised trouble for a national election – not the case here, where different parties are in power.

So O’Connell’s next paragraph, which criticises Federal Workplace Relations minister Bill Shorten and the Gillard government is very interesting. In an unprecedented move, Minister Shorten addressed an ANF statewide members’ meeting twice – first when we were voting on taking illegal, unprotected action, and then when Lisa announced an agreement. Were she colluding against members to ingratiate herself with the ALP, locally or nationally, such an overt endorsement would be most clumsy.

My reading of the Minister’s attendance and address, without any insider information or discussion, was as an indication of both his own and the ALP’s support for nurses and midwives, and a tacit promise of a more harmonious resolution next time around, should there be a Labour Premier in power.

While it’s true that some of the issues we faced this time were the result of the Rudd-era’s changes from WorkChoices to FairWork Australia as the industrial relations legislative framework, the seeds were sown by the previous Liberal government. I’d be delighted to see a return to an Industrial Relations Commission-style of IR legislation, but it, too, was flawed.

O’Connor’s final comment, that Prime Minister Gillard’s austerity policies contributed to our plight ignores the fact that public hospital funding is primarily and substantially at a state level – the responsibility here lies squarely at the feet of the Premier.

O’Connor now turns his attention back to the local stage, and to the ANF: “The union shut down the nurses’ strike action on March 7, declaring that the Liberal government’s agreement to negotiate through Fair Work Australia marked a ‘breakthrough.'”

As the entire point of the walk outs was to achieve a negotiated outcome with the oversight of an independent FairWork commissioner, ending the action is not “shutting it down” – members voted that the walkouts would continue until we had the government’s agreement to supervised negotiation. Had the strike action continued not only would participants be breeching the expressed will of members but would also have undermined any authority ANF had to negotiate on our behalf.

In the remainder of this paragraph O’Connell returns to the non-question of time to deliberate on the negotiated outcome – having been at the meeting where we voted to accept the outcome, having heard Lisa’s account of what we won, what we gave up, and where we compromised, and having read the EBA itself several times, I can find no section that is different from what I was told on March 16th.

One of the hallmarks of Lisa’s leadership is the patience she has with members questions – so many have been the times I’ve marvelled as she’s replied, with no sign of anything but interest, to the third consecutive moronic question that was already addressed half an hour earlier. At several meetings frustrated members have moved that we proceed to a vote, already, and Lisa’s responded by noting that there are still people with questions, stressing the importance of all present members understanding and agreeing with the proposal before us.

It is clearly unfeasible to consult with every member individually, and impossible to negotiate an outcome every single person will be happy with – if members want to know more than they have to make an effort to attend meetings, where they can hear information first-hand, and where they have the opportunity to ask questions.

Uniquely, in this case, the informal vote on March 16th was followed by an AEC-run ballot – with well over a month to reflect on the Agreement, with access to the EBA itself, and with plenty of opportunity to discuss it, the membership overwhelmingly voted in favour of the Agreement.

O’Connell moves on to the question of pay – for clarity and flow I’ll respond to his points out of order, starting with the matter of back pay. It is true that in every other EBA we have been back paid to the expiration of the previous Agreement – in this case that was a full five months before the nominated 2011/12 EBA start date, and that means a lot of unpaid back pay.

Premier Baillieu announced, within weeks of assuming leadership, that no EBA would include back pay. Even his cosy police agreement, which was achieved without significant wrangling, didn’t include back pay – like this government’s self-imposed 2.5% pay ceiling (which, oddly, didn’t apply to politicians), I suspect there is no likelihood of this being overtly breached.

There will, instead be tacit and covert arrangements that go some way toward compensation. For the police this was a one-off $1,000 bonus; for us it’s a bi-annual direct payment ($1000 the first year, $900 subsequently, pro rata’d for part-time staff) that’s ostensibly to assist nurses and midwives to meet the relatively new requirement we have a minimum of 20 hours per year of continuing education.

The funds do not need to be used for this purpose – for nurses in permanent employment the hours can be easily met with minimal exertion through inservices, and for all nurses and midwives independent study (reading journal articles, for example) counts, along with education packages , conferences, seminars, and even supporting students. If I ignore the conferences I went to last year I’ve managed over 200 hours of education in the past twelve months, without trying, and for the most part without significant expense.

The bonus may not form part of our base rate, and that means casual staff won’t receive it, but it’s pay that comes without strings, and which we neither had before nor that was given to us by the government but was instead fought for by our officials, so my position is that it therefore can be calculated.

“One category of nurses,” O’Connell notes, “is now so poorly paid that a 2.5 percent annual wage increase, plus the professional development allowances, is equivalent to a 21 percent rise over four years.” What he omits to tell the reader is that this category is our highest-earning nurses – before the CPD allowance Directors of Nursing will earn between $1,575/week (for a hospital of 13 beds or fewer) to $2,491.50 (for a 701+ bed hospital) at the beginning of the Agreement, rising to $1,696.20 – $2,683/week respectively. Like all public hospital employees, DONs are entitled to salary packaging, reducing their taxable income.

The final criticism O’Connell makes regards the new clause which gives employers the possibility of altering nurse/midwife: patient ratios. Having just today addressed this very question with a concerned member, I can appreciate why this gives rise to anxiety – ratios are, in Lisa’s words, Victorian nursing’s first-born child.

Here’s O’Connell’s take:

“Previously, hospital management required the express permission of affected nurses to operate shifts below the mandated ratio. Now, however, all that is needed is that ‘the employer must consider the consequences of any proposal to go below ratios, in good faith’, supposedly taking into account various factors including ‘nursing staff satisfaction’ and ‘quality of care/clinical risk.’ The union claimed that such ‘strict criteria’ would only be warranted in ‘very limited circumstances’, but the reality confronting ordinary nurses will be very different. The clause will be mercilessly exploited by hospital management desperate to cut spending in line with federal and state government directives.”

What he doesn’t mention is that this is a modification of old Clause 42, which allowed for redistribution of staff and above-ratio patient loads under some circumstances. The same considerations apply – before any change can be made, all relevent issues must be addressed. Key among these are nursing-sensitive patient outcomes – patient complications (like pressure sores, falls and medication errors) that lessen with higher numbers of nurses and soar once nursing numbers are cut.

The only wholly new component is Clause 42.4, which allows the supervised trial of alternative staffing models, but only with review, and with reversion to the ratios unless previous benchmarks are met or surpassed.

This clause is the only section of the EBA that could be termed ‘regressive’ – though this is the way O’Connell refers to the Agreement in toto. He quotes an unnamed nurse who posted online her (or his) opinion that the government used ratios as a red herring to distract us from a financially based campaign. I believe that the focus every government has had on losing ratios belies this – had we agreed to sacrifice safe staffing we could have gained far higher pay increases, at the cost of the system.

Though he has not demonstrated it throughout the article, O’Connell describes the ANF outcomes as a ‘betrayal’, unsurprisingly concluding with the SEP refrain:

.. it is impossible to fight for nurses and other sections of workers to fight for their basic rights within the straitjacket of the trade unions. As the Socialist Equality Party has raised from the outset, what is needed is a rank-and-file rebellion against these organisations and a political fight against the state and federal governments on the basis of a socialist perspective.

With that philosophy as a fundamental plank of SEP policy, there is no union-based outcome that would ever satisfy O’Connell.

As I noted a few days ago, nurses and midwives are not a radicalisable population. I dearly wish there were – perhaps, had more nurses and midwives been more invested in the EBA we would have had an even stronger, and certainly faster, result. Here’s the thing, though – they’re just not. There will not be a rank-and-file rebellion, and given the numbers of nurses I know who voted for the current Premier, there is no chance is a widespread adoption of a Socialist platform by nurses and midwives.

We did not get the best-in-all-worlds outcome. We did, however, get the best outcome possible in this world, with this government, and this membership. The radical approach advocated by the Left wing would have meant leaving behind the overwhelming majority of our membership; that is not only contrary to the ethos of the Federation, it would have resulted in a weaker, poorer outcome.

My position is that organisations and movements need leaders. I believe the best interests of my profession, and of the population I serve, are met by elected officials who understand the demands of my work, the nature of the challenges I face, and the priorities of my colleagues. Some unions represent multiple interests, which seems to me almost by definition to mean that at least some of the time there will be conflict between the interests of different parties – ANF only represents nurses and midwives, its’ officials (and majority of staff) are nurses and/or midwives, and the Federation’s priorities are member-led. We got the EBA we were prepared to fight for. Many of us fought long and hard, and we are happy.

2011 – the issues
In the run up to an enterprise bargaining agreement each side creates a log of claims – the ANF’s claims are based on motions from representatives at the preceding years’ Delegates conferences, where job reps from around the state meet, raise, discuss and vote on proposals. These might centre on a need to change staffing to reflect a change in acuity, or the addition of a new or revised condition – for example, the option to gift sick leave to a colleague. Periodically a proposal that job reps pay reduced membership fees is raised, and voted down – we want to retain reps who are primarily interested in the best interests of the membership as a whole.

The government has its own log of claims, which are usually submitted three or four months prior to the expiration of the agreement and which are generally less expansive than ANFs’ both in terms of content and form. That said, this time around they were more bald than I’ve seen previously, with such useful entries as “review ratios”. This was part of a larger strategy (see “duplicity” below).

I imagine that ANF was prepared to defend the ratios yet again. What was new were the proposals to introduce minimally trained staff, and to dramatically reduce staff hours – the refrain to which VHIA (the government’s negotiating agent) continually returned was ‘flexibility’. So why were these aspects important?

Ratios
I’ve previously discussed the significance of ratios in terms of both improved patient outcomes (fewer complications, better care, shorter hospital stays) and workforce benefits (less burnout, lower turnover, improved overall retention, the return of former nurses to active practice). I don’t expect governments to care about happiness, job satisfaction or professional development, though it would be nice if they were considered important. However, on both fronts these results mean cost savings to government.

The nursing budget comprises a significant portion of all hospitals’ running costs, and therefore a source of temptation for governments looking to reduce operating costs. The nursing budget is high because nursing care is the primary reason for admission – patients who can manage without nursing care are treated as outpatients. There is a large, overwhelmingly unanimous body of local and international research that clearly links a decrease in the education and experience level of bedside care with an increase in falls, pressure injuries, iatrogenic infections, pneumonia, medication errors, clinical errors, failure to escalate care in the deteriorating patient, ICU admissions, preventable re admissions, morbidity and mortality.

In one study each additional patient assigned to a nurse resulted in a 7% increase in both 30-day patient mortality and failure-to-rescue rates, a 15% increase in job satisfaction and a 23% increase in nurse burnout. Increasing nurses’ workload for four patients to eight increased the likelihood of death within 30 days of admission by 31%. Atencio et al (2003) estimate a cost of US$92,000 to replace a general nurse and up to US$145,000 to replace a specialist nurse – these figures are nine years old, but even ignoring inflation and differences between the US and Australian systems, that’s a lot of money that could be saved by reducing burnout and dissatisfaction. For a broader view of the benefits of ratios see here; Curtin provides a great overview of the research around improved outcomes and a skilled workforce, which brings me to the second spear in the government’s attack.

Skill mix
The government strongly endorsed the introduction of aides (variously titled health care workers, patient care attendants or nurse aides) into Victoria’s acute hospitals, and would count them in the ratios. While the government publicly professed that they would retain current ratios, even going so far as to state that they aimed to employ additional nurses across the state, including the acute care sector, and to invest in retention and recruitment programs, this was quite clearly in the name of public relations rather than a statement of intent.

As I wrote to the Health Minister’s Executive Director during the campaign, I suspected we had quite different ideas about what the retention of ratios means in practice, and possibly their understanding of the definition of “current”. At present the ratios, which I will for the purposes of clarity and brevity assume to be 1:4 (while recognising that different hospital categories, clinical areas and shifts have different ratios), apply to the number of patients each nurse has. Maintaining the current ratio system therefore means the retention of six clinical nurses, plus a supernumerary nurse in charge, for every twenty-four patients. Any proposed alteration to that – be it the replacement of one nurse with a minimally-trained worker, or the removal of a single nurse for a portion of the shift – does therefore not support current ratios.

Patient care workers are not nurses. Perhaps 80% of the tasks that I do could be performed by someone with minimal training – I could, for example, teach you how to perform a bed bath in around an hour. However, the tasks are less than 50% of my role; the rest is assessment and the utilisation of education and experience. When I perform a bed bath I am not just washing my patient – I am assessing their skin, the condition of their heels and occiput, looking at the integrity of dressing, whether there is a positional increase in flow from drains, assessing ease of movement and non-verbal indicators of pain, comparing how well the patient is able to assist in their care now versus last week, noting positional orthopnea and exertional dyspnoea, assessing affect, and watching for postural hypotension when the patient is returned to a sitting position. I am, at least as importantly, also creating a unique space for the patient to talk – washing is a time of vulnerability and intimacy, often the only uninterrupted time the patient has, and very often when patients will ask questions or disclose information essential for their care and recovery. I have been privilege in my career to thrice been the sole recipient of a disclosure that my elderly patients were the victims of childhood sexual abuse – each disclosure was made while I assisted the patients with hygiene care, and each time it was some way in to the therapeutic relationship, after the development of a strong rapport. This does not happen when care delivery is fragmented – such as when the hygiene is performed by an aide as a task rather than by a nurse as part of holistic care.

Though the aspects I’ve discussed are important for the comfort and well-being of the patient, they are also of significant clinical use. For example, observing pain on repositioning means better analgesic coverage, which means an increased ability to move, which in turn reduces rates of deep vein thrombosis and chest infection, both of which significantly affect length and therefore cost of stay.

Nursing is not about tasks, though there are certainly tasks that need to be performed. Good nursing care – care that promotes patient welfare, shortens hospital stays, reduces preventable re-admissions and meets patient needs – is holistic and coherent. It meets the physical, clinical, psychosocial and spiritual needs of the people at the centre of our health care system. Patients who are critically ill, and that’s an increasing percentage of acute sector inpatients, need frequent assessment by skilled staff who are able to detect small but significant indicators of deterioration. In acute care there is no such thing as a low-priority task that can be performed by someone without the necessary background and education.

That’s the patient side of things – for practitioners, the other key sticking point was that we would be legally responsible for the actions of these people who had a few months training and no accountability.When I supervise a student, she or he is responsible for their scope of practice – I have some accountability and oversight, but if Jo decides on her own and without my consultation to give Mr Brown paracetamol he wasn’t prescribed then she is responsible for his anaphylactic reaction or worsening liver function, not me. Under the VHIA proposal, if an aide did the same thing, I would be legally held responsible. So to that members said, with one voice, no.

Hours and staff deployment
The final ‘flexibility’ measure was a joint proposal – first that nurses could be redeployed, without notice, and even in midshift, not just to other wards and departments but also to other hospitals within the same network. We can set aside the effect this would have on patient continuity (which in itself increases the likelihood of avoidable complications), on the workload of the colleagues who would be taking over our abandoned patients, and on nursing satisfaction.

This proposal clearly demonstrated that the VHIA, with whom we were negotiating, saw nurses as interchangeable pieces with minimal specialist skill, and I believe this explains a lot about the opposition we received throughout. I received a comprehensive general education – the change in education in the interim means that few if any recent graduates would have the same breadth of experience, because I rotated through every ward and department at my hospital, as well as specialty rotations in pediatrics, midwifery, ICU, theatre, emergency, psychiatry, community health, and district nursing.

These experiences were invaluable for two reasons – they informed my cureent practice, and they allowed me to know early on which areas I enjoyed (medical nursing) and which I did not (theatre, pediatrics). They did not equip me to work in those areas twenty years later. Yes, I could provide care for a child, a burns patient, or an emergency patient. But those people would not receive the same care as they would from a nurse who specialised in those areas, and in some cases my lack of expertise and knowledge could result in death or avoidable complications – I don’t know how to read variations in cardiac telemetry, what to look for in a patient fresh from neurosurgery, or how to delivery cytotoxic chemotherapy.

In addition, VHIA proposed the introduction of unlimited short shifts (as little as four hours) and split shifts – where a nurse might work for four hours in the morning, go home (or somewhere) for two, four or six hours, then return to the ward for another few hours. Split shifts were outdated in the seventies, when nurses still predominantly lived onsite.

Duplicity
The Health Minister, David Davis, denied in December that split shifts were suggested , but he had little believability – in May 2011 he submitted a Cabinet-in-confidence document, later leaked to The Age, where he and his department recommended trying to force ANF into compulsory arbitration – under the current industrial relations legislation that meant there would be no possibility of shift length, work load (the ratios) or skill mix (the introduction of aides) into the EBA.

Two months later he told nurses that the Liberal government was committed to fair negotiations, and to ratios; six months later he was telling the public the same thing, though his recommendations included slashing $104 million dollars from the states nursing budget – the equivalent of over 1700 full-time jobs.

Other proposals in the document included a suggestion that the government’s log of claims be “publicly presented in a broad manner so as to be as small a target as possible for inevitable ANF criticism, but still position employers for any arbitrarial proceedings that might eventuate” (point 18).

Lisa Fitzpatrick can articulate the nursing position far better than I – here’s a clip of her address to a group of nurses and community members in Colac:

Background – ‘acuity’?
‘Acuity’ is a portmanteau concept that describes (without specificity) both the overall population of a ward (or hospital as a whole), and the relative sickness of a patient, the amount of care they require, and how precarious their position is. If the ward is very acute then we have a larger than average number of sick patients who require high level, skilled care. For laypeople anyone in hospital is, by definition, sick; for staff ‘sick’ means something very different – it means that we have serious concerns about the patient’s potential to deteriorate, either because their disease is rapidly progress, or failing to respond to treatment, or their underlying pre-existing conditions (co-morbidities) are significant and/or worsening, or that the patient may not have the reserve to continue to fight. If I report to my supervisor that I’m concerned about a sick patient, what I mean is that I have a better than even concern that the patient will need urgent intervention over the next few days or even hours – anything from an urgent medical review when they drop their blood pressure, to a transfer to ICU (possibly via theatre) or even full resuscitation.

Defending the ratios: from 2001 – 2007
Nurses and midwives in Victoria care for more patients, at less cost, with shorter bed stays than at any other time. Although local and international research consistently demonstrates that lowering the number of patients nurses and midwives care for results in better outcomes (fewer preventable complications, fewer errors, faster detection of deterioration, a dramatic shortening of admission length, fewer ‘failure to rescue’ incidents) at lower cost, every single Victorian government since 2000 has tried to weaken or remove ratios from Victoria’s public hospital system.

We weren’t given ratios in 2000 by the then-government – after almost a decade of savage cuts under the Kennett government, Victoria’s public health care system was in crisis – in 1992 there were 83,276 nurses registered in Victoria; just seven years later that figure had dropped to 69,794. The most significant factor was workload – they became untenable, as nurses were having to care for more patients, with higher acuity.

As ANF entered negotiations in 2000 it quickly became obvious that there was no common ground between the parties, and after negotiations stalled the dispute was brought before the now-defunct Australian Industrial Relations Commission, in the person of Commissioner Wayne Blair. After hearing long and involved arguments from both sides, the Commissioner accepted the ANF position that nurses are integral to an effective health care system, that the Victorian health care system was critically understaffed and underfunded, that the large-scale and ongoing departure of nurses must be reversed, and he decided in favour of introducing the world’s first ratios in order to reverse the exodus and thus return the system to health.

Yet only a year later we had to return to the fray, fighting this time for funding to ensure the ratios could be implemented fully (for a contemporaneous account of the introduction and first defence of ratios, click here). And every single time since then Victorian public sector nurses and midwives have renegotiated our pay and conditions (under an Enterprise Bargaining Agreement, which lasts from three to four years) we have had to take industrial action to defend ratios – first in 2001, again in 2004, and most bitterly in 2007.

In 2007 changes in industrial relations law meant that government had the option of docking employees who took industrial action. Despite the this threat, the 2007 campaign was the most united and coherent I’d been involved in – campaign shirts were launched at the Delegates conference in July, where reps were briefed on the fight that lay ahead of us.

If you look closely you can see me in the bottom left-hand corner

Along with thousands of other nurses, and in the face of (what was for me) unprecedented employer harassment, I closed beds on my ward – usually running at thirty-two patients, every nurse chose to close one bed. Normally, we would group those beds into one area, so only one nurse was financially affected, and so that (at least during the day) a nurse could go down to Emergency to help out, because patients don’t stop coming in just because there are no beds. However, ward and hospital management wouldn’t allow grouping of beds, and their efforts to intimidate staff into opening beds merely strengthened our resolve. I was working weekend night duty, responsible for three other nurses and twenty-eight patients, including seven for whom I was directly providing care, and I was docked every cent. The funds were eventually reimbursed to all docked nurses, when ANF won a case supporting the position that employers had discretion over docking. And once again, if accordance with the majority consensus among nurses and midwives working in the system is that ratios are more important than any other condition, we won by agreeing to lower pay increases in order to retain ratios.

I will forever remember the final meeting of the 2007 campaign – things had been so unrelentingly grim, and the pressure from management so unrelenting and intimidatory, that I was convinced ANF (Vic branch) Secretary Lisa Fitzpatrick would be recommending strike action – so much so that I had already approached my parents about borrowing money to cover my rent and other expenses. The turn out was so great that we abandoned our usual venue, Dallas Brooks Hall, for the larger capacity of Festival Hall. The first big union to defy the government in a post-WorkChoices world, the street to Festival Hall was lined with members and officials of other unions, cheering us on.

The atmosphere inside was electric, the venue was a sea of red, and the atmosphere was a heady combination of grim determination and tightly held excitement. When Lisa stepped on to the platform, some ten minutes late, the room was hushed – and after a greeting her first words were “I have an Agreement I’m happy to recommend.”

At the very last minute the Bracks government agreed to almost every claim, and ANF’s concessions were minimal and predominantly tokenistic. It was an overwhelming victory for the union and a testament to both the resolve of our members and the determination of our officials. The 2007 campaign was the most heated, prolonged and intimidatory I’d been involved in – though not on the scale of the 1986 Strike, it prepared the membership for the fight that we were to face four years later, under a very different government.

In 1986 Victorian nurses went on strike for fifty days – it was only the second time nurses here had done so – the first time, for five days in 1985, was part of the same campaign, though nurses didn’t realise it at the time. I was in my final year of high school and, though I was aware of the Strike at the time, it wasn’t until I began my training in mid-1989 that I began to understand it – the Strike formed a substantial part of our history of nursing studies, and it was recent enough that many of my instructors, Charge nurses, registered nurses and advanced students had taken part or been affected. There’s an excellent overview of the Strike here.

When I began on the wards our staffing was based on a daily patient dependency score that weighted factors like the age of the patient, linen changes, frequency of observations, and complexity of dressings to arrive at an aggregate that measured patient care hours over a full day – an 18 bed ward might have a couple of category 1s (essentially ambulant and self-caring), seven or eight each category 2s (some IV medications and a dressing) and 3s (ambulance with assistance or a hoist, four-hourly observations, an extensive dressing) and one or two category 4s (bed-bound, full care, a tracheostomy, frequent medications, incontinent).

The scoring was unavoidably retrospective, and staffing was based on scores from the month before. If your ward was particularly light you could be sent to another ward with heavier needs, sometimes mid-shift but usually at the beginning of the shift (students were almost always sent over registered nurses, and the individual was determined either by who arrived last or, on fairer wards, by consulting the sent book to see who’d had longest without being sent).

After I was registered the dependency calculation slowly faded away, and effective full-time (EFT) staffing was based on an opaque assessment of the ward specialty and typical patient load – when the ward seemed particularly heavy and we were missing tea breaks or running relentlessly we’d be told that we were “at EFT” however it felt on the floor. Sick leave wasn’t always replaced, and I clearly remember a night in the late ’90s where another RN and I, along with an agency enrolled nurse (pre-medication endorsement, who had only ever worked in an aged care facility, and could only help with bed turns and changes) cared for 26 patients without a break and without even enough time to check drugs with each other – something that was then against hospital policy, if not illegal. It was purely thanks to good luck there wasn’t a tragedy.

In 2000 the then-secretary of the Australian Nursing Federation, Belinda Morieson, spearheaded a campaign that resulted in the world’s first nurse/midwife: patient ratios – instead of flawed patient dependency systems determining how many patients nurses were allocated, a transparent ratio (based on hospital status, ward type, and shift time) meant that a maximum safe number of patients could be allocated to nurses or midwives.It’s often simplified to “1:4 – one nurse for four patients” but that’s not quite the case. On the general wards of a class one hospital (like the Royal Melbourne or the Austin) plus a supernumerary in-charge nurse and five nurses are rostered for twenty patients (six for twenty-four etc) on a day shift, but the actual allocation of patients is dependent on skill mix and patient acuity, so one nurse might have six stable patients while another has one very sick patient and an ambulant, self-caring patient (this last is something of a unicorn in the current system).

That means that a tertiary metropolitan hospital has different ratios than a small rural hospital, that nurses on a rehabilitation unit have more patients than nurses in coronary care, and that there are fewer nurses on night shifts (and, in some places, afternoon shifts) than on mornings.

Instead of feeling overloaded and unable to meet patient needs, but being told that we were adequately staffed, it was now easy to see if we had sufficient nurses for our area. The dramatic fall in nursing numbers precipitated by the Kennett government’s health care “reforms” took some time to reverse, but eventually Victorian nurses and midwives came back to full strength – wards were no longer reliant on casual bank and agency staff to meet daily staffing shortfalls, which resulted in more consistent standards, less cost, and continuity of care.

Thanks to ratios Victoria does not have a nursing shortage, experienced nurses have been retained and even returned tot he system, and our patient outcomes have improved, but it has not come without a cost – as I will discuss tomorrow